"Brace technology" thematic series

Transcription

"Brace technology" thematic series - the
Gensingen brace™ in the treatment of scoliosis
Weiss
Weiss Scoliosis 2010, 5:22
http://www.scoliosisjournal.com/content/5/1/22 (13 October 2010)
http://www.scoliosisjournal.com/content/5/1/22
METHODOLOGY
Open Access
“Brace technology” thematic series - the
Gensingen brace™ in the treatment of scoliosis
Hans-Rudolf Weiss
Abstract
Background: Bracing concepts in use today for the treatment of scoliosis include symmetric and asymmetric hard
braces usually made of polyethylene (PE) and soft braces. A new asymmetric Chêneau style CAD/CAM derivate has
been designed to overcome problems the author experienced with other Chêneau CAD/CAM systems over the
recent years.
Brace description: This CAD/CAM Chêneau derivate has been called Gensingen brace™, a brace available to
address all possible curve patterns. Once the patients’ trunk is scanned with the help of a whole trunk optical 3Dscan and the patients’ data from the clinical measurements are recorded, a model of the brace can be created by
(1) modifying the trunk model of the patient ‘on screen’ to achieve a very individual brace model using the CAD/
CAM tools provided or by (2) choosing a brace model from our library and re-size it to the patients’ properties ‘on
screen’.
Results: End-result studies have been published on the Chêneau brace as early as 1985. Cohort studies on the
Chêneau brace are available as is a prospective controlled study respecting the SRS criteria for bracing studies,
demonstrating beneficial outcomes, when compared to the controls using a soft brace. Sufficient in-brace
correction effects have been demonstrated to be achievable when the Chêneau principles of correction are used
appropriately. As there is a positive correlation between in-brace correction and the final outcome, the Chêneau
concept of bracing with sufficient in-brace corrections as published can be regarded as being efficient when
applied well. Case reports with high in-brace corrections, as shown within this paper using the Gensingen brace™
promise beneficial outcomes when a good compliance can be achieved.
Conclusions: The use of the Gensingen brace™ leads to sufficient in-brace corrections, when compared to the
correction effects achieved with other braces, as described in literature.
According to the patients’ reports, the Gensingen brace™ is comfortable to wear, when adjusted properly.
Further studies are necessary (1) in order to evaluate brace comfort and (2) effectiveness using the SRS inclusion
criteria.
Introduction
Bracing concepts in use today for the treatment of scoliosis include symmetric and asymmetric hard braces
usually made of PE on the one hand and soft braces on
the other. The latest developments in the field of bracing, aim at (1) improving specificity with respect to the
individual curve pattern of the patient treated and (2) at
a restoration of a proper sagittal realignment [1,2].
Although the effect of brace treatment has been questioned [3], there is evidence that brace treatment can
Correspondence: [email protected]
1
Orthopedic Rehabilitation Services, D-55457 Gensingen, Alzeyerstr. 23,
Germany
stop curvature progression [4-9], reduce the frequency
of surgery [10-12] and improve cosmetic appearance
[13-15]. Poor cosmetic appearance for the patient may
be the most important problem, which can be solved or
at least reduced by the use of advanced bracing techniques including the best possible correction principles
available to date [13].
The plaster cast method worldwide seems to be the
most practiced technique for the construction of hard
braces at the moment. CAD (Computer Aided Design)
systems are available, which allow brace adjustments
without plaster. Another new development is the ScoliOlogiC™ off the shelf system enabling the technician
© 2010 Weiss; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
to construct a light brace for scoliosis correction from
a variety of pattern specific shells to be connected to
an anterior and a posterior upright [1]. This Chêneau
light™ brace, constructed according to the Chêneau
principles using the brace parts from the ScoliOlogiC™
off the shelf system, promises a reduced impediment
of quality of life in the brace. A satisfactory in-brace
correction exceeding 50% of the initial Cobb angle has
been achieved with this brace [2], which was used as
the basis for the development of the Gensingen brace™
(Fig. 1).
History of the Gensingen brace™
The Gensingen brace™ is a Chêneau derivative in principle. The Chêneau brace was developed before 1978 [16].
As the first developments were made in Münster, Germany, the brace was initially called CTM-brace (Chêneau-Toulouse-Münster). Jacques Chêneau, who used to
live in Toulouse, spent a few years in Münster, where
he braced patients at the orthopedic department of the
university. In 1985 the first end-result study was published with in-brace correction effects of more than 40%
of the initial value [7] and final results superior to the
end-results of the Milwaukee study from the same centre [17] (Fig. 2). The initial Chêneau brace was upgraded
in 1995 and from this year on, a new version each year
Page 3 of 18
was promoted by the inventor during the courses organized in Germany together with Dr. Weiss in Bad
Sobernheim and Prof. Neff in Berlin. A working relationship between Dr. Chêneau, Dr. Weiss and Dr. Rigo
began in Bad Sobernheim towards the end of the 90’s,
which resulted in a collaboration publishing a book presenting the 1999 standard of the Chêneau brace [18].
At the beginning of the new century Dr. Chêneau was
working on the first CAD/CAM system supported by a
company called IPOS.
Other CAD/CAM systems developed in Germany
applying the Chêneau principles, such as the Regnier™
system and the RSC™-brace.
In the summer of 2006 the fabrication of the ScoliOlogiC® off the shelf bracing system for the adjustment of
Chêneau light™ braces began.
The Chêneau light™ brace is available for right thoracic and left lumbar curvatures, only. For thoracolumbar
curvatures no Chêneau light™ shells are available.
Another limitation for the application of the Chêneau
light™ brace is the limited number of shell sizes not
allowing to brace patients with small trunks as well as
in children aged ten or under.
Therefore, in our department it has been necessary to
use plaster based bracing or a CAD/CAM system in
addition to the Chêneau light™ brace.
Figure 1 Gensingen brace™ for the correction of a functional 4-curve scoliosis.
Page 4 of 18
Figure 2 Patient from North America with a thoracic curve of 56° initially treated with a Milwaukee brace (upper line of pictures). The
curve corrected from 56 to 53°, only. The same curve has been corrected to 27° in a Chêneau brace with a good clinical and cosmetic
intermediate result. Nevertheless, the patient from North America finally decided to have spinal surgery, although the Chêneau brace treatment
seemed promising.
At first, we considered using a CAD/CAM system that
was already available. However, the Regnier™ system still
today does not address the sagittal profile accordingly
and the RSC™ braces still have a high percentage of
rotation instability [19]. The latter may lead to a loss of
the correction initially achieved after a few weeks of
brace wearing [19].
Therefore, with the help of Orthomed Scoliocare,
Orthopedic Technical Services in Gensingen a new
CAD/CAM system was developed in Spring 2009 with
the aim to overcome the shortcomings of the CAD/
CAM systems already available in Germany and to
enable brace adjustments for patients of all possible
curve patterns (Fig. 3 and 4) and trunk sizes.
A slight lumbar lordosis has been introduced into the
braces included into our library (Fig. 5), which can be
augmented by using foam pads and the “Stop Point”
against rotational forces (Point 37 according to Chêneau) has been set laterally in order to have a better
relation to the anterior superior iliac spine on the ribhump side.
Although, dependent on the pelvic geometry of the
individual patient, we are still experiencing some rotation instabilities in the new design, we have been able to
reduce this problem drastically.
Theoretical principles
Many 3-point pressure systems are applied on the frontal, coronal and sagittal plane as in all other Chêneau
derivates. Opposite every pressure area an expansion
void is implemented. This enables the desired corrective
movement and - when adjusted properly - avoids
Page 5 of 18
Figure 3 Three examples of Gensingen braces™. On the left there is a brace to address a double curve (3CL, 4C), in the middle, a brace to
address single thoracic curves (3C, 3CH) and on the right, a brace for the treatment of a thoracolumbar curve pattern.
Figure 4 Different Gensingen braces™ on the patient’s body. On the left for a 3C scoliosis: The decompensation to the right has been
overcorrected with the trunk being hyper compensated to the left in the Gensingen brace™ 3C. The middle picture shows a patient with right
lumbar scoliosis in a Gensingen brace™ 4CL. The pelvis is hyper compensated from left to the right and the thoracic counter curve seems well
balanced in the brace. On the right, a patient in a Gensingen brace™ 4C is documented. Pelvis is hyper compensated from right to left and the
thoracic area is hyper compensated in the same direction.
Page 6 of 18
Figure 5 Sagittal alignment of a Gensingen brace™ 4C. On the right the implementation of a physiologic sagittal profile is visible with a
pronounced lumbar lordosis and a slight thoracic kyphosis.
compression effects leading to pressure sores. As a matter of fact, in today’s Chêneau braces pressure sores
have become a very rare complication.
The brace action is demonstrated on morphing videos,
which can be seen on the links provided: http://www.
youtube.com/watch?v=sd9mbyzXflQ and http://www.
youtube.com/watch?v=9uNZmY6jQas.
Pattern specific bracing is desirable to allow the correction of the individual curve patterns appropriately, as
theoretically there might be an unlimited number of
curve patterns with different geometrical entities.
Therefore, a classification is necessary to come as close
as possible to the individual pattern of the patient in
order to address the biomechanical properties of the
individual curve pattern of the patient treated.
After the first curve patterns were identified by Ponseti
and Friedmann [20], and Moe and Kettleson [21] for surgical means, in the late 70’s a simple functional classification for approaching different curve patterns with the
help of physiotherapy was established by Lehnert-Schroth
[22,23]. This classification simply distinguished between
so called (functional) 3- and 4-curve patterns.
Chêneau also used this simple classification for the
construction of his braces.
The King classification [24] distinguished between 5
different (thoracic) curve patterns and was established in
the 80’s to help the surgeons to approach the curves
properly during operations.
The Lenke classification [25], which is rather complex
was developed by surgeons, because the use of the King
Classification had lead to imbalanced post surgical
results and seemed to lack reliability.
Rigo [26] implemented a new classification for brace
treatment with 15 different curve patterns, derived from
the Lenke classification [25]. All those curve patterns according to his opinion - demand individual principles
of correction in 3D, however, 5 key patterns have been
identified which we have started working with in everyday practice [27].
Page 7 of 18
This year Rigo came up with a brand new classification [28], which, in our opinion is not simple enough to
be used by technicians and CPOs generally.
Therefore, at our center we are now returning to the
simple functional classification by Lehnert-Schroth
[22,23]. The principal subdivision of functional 3 and
functional 4 curves still seems to work for physiotherapy
and can easily be augmented to the needs of the technician or CPO. This augmented Lehnert-Schroth classification [29] can be seen on Fig. 6 as well as the braces
used to address the individual curve patterns.
Brace description
The advantage of the Gensingen brace™ is that the brace
is available in a short time (3 days with overnight
milling service, or even shorter), is easily adjustable and
is very comfortable to wear, because many compression
Figure 6 The augmented classification according to Lehnert-Schroth. Curvatures decompensated to the thoracic convex side have to be
regarded as functional 3-curve type curvatures, when balanced or decompensated to the thoracic concave side (lumbar curves as big as
thoracic ones or even bigger) per definition they are functional 4-curve types. As can be seen, the 3-curve lumbar is a 3-curve pattern, but
treated like 4-curve with reduced correction in the lumbar curve.
effects - in frontal and sagittal plane as well - apparent
within other specific, non symmetric CAD/CAM systems - have been ruled out in this system of bracing. As
a matter of fact many other CAD/CAM Chêneau derivates lack a balanced distribution of pressure areas.
Braces to address functional 3-curve patterns (Fig. 7)
and braces to address functional 4-curve patterns (Fig. 8)
are available, as are braces for thoracolumbar curve patterns (Fig. 9). There are more than 35 different braces in
our library including models for athletic trunks as well as
models for small children. No extra models are used for
double thoracic curvatures as these easily can be addressed
by fine adjustment of the models from the library.
The brace is usually adjusted to the patients’ body
with the help of the pattern specific blueprints (Additional file 1.) as a raw “try on” brace first as it has been
cut from the foam positive (Fig 7, Fig 8, Fig 9). The construction of the Gensingen brace™ from the milling of
the foam positive to the fine adjustment to the patient’s
body can be seen on the first part of the video on the
link: http://www.youtube.com/watch?v=0P9eKW0Fpis.
Page 8 of 18
Practical issues
How to prescribe the brace
The Gensingen brace™ at our centre is not prescribed
per se. The prescription does not contain the specific
brace name, but a Chêneau brace is prescribed and the
curve pattern of the individual patient is also submitted.
The Cobb angles of all curvatures should also be visible
on the prescription.
Additionally, a construction plan (e.g. in Additional
file 2.) for the brace prescribed is attached to the prescription and should a brace have to be renewed, a
further sheet giving justification (Additional file 3.) as to
why a new brace has to be prescribed should be
included.
With this Chêneau prescription, the patient can go to
any workshop near home to get his or her brace done
using plaster casting, CAD/CAM system braces or Chêneau light braces. If the patient makes the decision to
go to the workshop in Gensingen, the CPOs show
diverse possible Chêneau derivates so as to enable the
patient to decide on the brace type her- or himself.
Figure 7 A brace to address functional 3-curve patterns for right thoracic curves from all four sides. The static overcorrection to the
concave side is already visible in this “try-on” brace not yet cut and finalized. A final 3-curve brace can be seen on Fig. 4. on the left. The final
brace is much smaller than the ‘try on’ brace.
Page 9 of 18
Figure 8 A brace to address functional 4-curve patterns for right thoracic and left lumbar curves from all four sides. The static
recompensation of the trunk segment is already visible in this “try-on” brace not yet cut and finalized. A functional 4-curve pattern brace in its
final form can be seen on Fig. 4 on the right. The final brace is much smaller than the ‘try on’ brace.
Figure 9 A short brace to address the thoracolumbar curve pattern 4CTL. The static overcorrection to the thoracolumbar concave side is
already visible in this “try-on” brace not yet cut and finalized with pelvic prominence mirrored. A final 4C-curve short brace can be seen on Fig.
4. middle. The final brace is much smaller than the ‘try on’ brace.
Page 10 of 18
Figure 10 Whole trunk scan of a patient with right thoracic scoliosis. The decompensation is clearly visible. To paste some markers on the
trunk before the scan is taken makes it easier to identify special landmarks of the trunk while modifying the trunk model in the computer with
the help of the CAD/CAM tools provided.
When the Gensingen brace™ has been chosen the CPO
firstly performs a trunk scan (Fig. 10) and then starts to
take the measurements necessary for proper brace
adjustment as has been demonstrated on the linked
video: http://www.youtube.com/watch?v=0P9eKW0Fpis.
How to build the brace
Once the patients’ trunk is scanned with the help of a
whole trunk optical 3D-scan and the patients’ data from
the clinical measurements are recorded, a model of the
brace can be created by (1) modifying the trunk model
of the patient ‘on screen’ to achieve a very individual
brace model using the CAD/CAM tools provided or by
(2) choosing a brace model from our library and re-size
it to the patients’ properties ‘on screen’. In rare curve
patterns the individual correction of the trunk scan is
used, in curve patterns classified easily, the second procedure is usually chosen. In this case the patient has the
advantage to receive a fully developed brace, where all
known disadvantages of other bracing systems have
already been ruled out as far as possible [19]. Individual
modelling is not as safe with respect to in-brace correction and may be more uncomfortable at first. A visual
impression on how the model is milled, vacuumed and
how the brace is finally adjusted can be found on the
linked
video:
http://www.youtube.com/watch?
v=0P9eKW0Fpis.
Page 11 of 18
How to check the brace
Exercises
The brace is checked in a standardized way. First of all a
verification of the pattern specificity is necessary, after
that the pad (pressure area) attachment is checked clinically for the right height in relation to the neighboring
pressure areas and voids. The voids are then controlled
for the impact the construction clinically might have on
the patient with respect to pain and other discomfort.
This is done by the CPO first and is documented on the
“Checklist” (Additional file 4.)
After that, the CPO presents the patient and the
checklist to the physician, who has another checklist
(available in German only, Additional file 5.) for the
final clinical check-up.
After the necessary improvements have been made, the
patient is scheduled for the next appointment in 6 weeks
in order to have a clinical check-up and the in-brace xray completed using pad markers (Fig. 11, 12, 13).
There are no exercises done in the brace because we
aim at maximum possible correction giving no room for
further corrections with the help of exercises. However,
for the exercises without the brace on, the augmented
Lehnert-Schroth classification is also applied (http://
www.youtube.com/watch?v=eHsCsL7IEaU).
Protocols
The criteria for bracing are taken one to one from the
SOSORT indication guidelines [30].
Everyday usage
the number of hours per day that the patient should
wear the brace in principle is taken one to one from the
SOSORT indication guidelines [30].
Results & case reports
At least in Germany the Chêneau brace has been widely
reviewed. As early as 1985 the first end-result study was
published [7]. The average in-brace correction reported
on within this study was 40%. Landauer [6] presented a
case series of patients treated with the Chêneau brace
with comparable in-brace corrections and comparable
end-results.
A prospective controlled study comparing the Chêneau brace with the SpineCor has clearly shown the
superiority of the Chêneau brace in a sample of patients
at actual risk for being progressive, fulfilling the SRS criteria for studies on bracing [9]. After growth only 8%
from the SpineCor sample and 80% of the Chêneau
group were not progressive. The Cobb angle at the start
of treatment however, was 21° for the SpineCor sample
and 33° for the Chêneau brace sample of patients.
Figure 11 14-year old boy in his second Gensingen brace™ for the treatment of a double thoracic curvature. The initial angle of
curvature at the start of treatment, when the boy was 12 years old, was 35° main thoracic with a significant high thoracic counter curve
exceeding 30° as well. Now in his second Gensingen brace™, version 2010 for the treatment of a double thoracic curvature we have achieved a
correction from 27° (intermediate result) to 12° in the main thoracic curvature, which is excellent considering the fact, that double thoracic
curves cannot be corrected as easy as single thoracic curves. The foam pad location is marked on the in-brace x-ray with wire as is the
longitudinal width of the thoracic pad.
According to Landauer and collaborators, [6] two factors are influencing the outcome of brace treatment,
both of them being equally important: In-brace correction (1) clearly correlates with the final result. The better the in-brace correction, the better the end-result.
Compliance (2) is the other important factor. The best
possible in-brace correction will not change the prognosis of the patient when the brace is not worn as
prescribed.
In-brace corrections exceeding 50% have been
reported in literature in a sample of patients treated
with the Chêneau light™ brace having an average Cobb
angle of 36° [2]. The Gensingen brace™ is adjusted
according to the same principles of correction as the
Chêneau light™ brace [31], therefore we expect similar
results in both brace types.
As the majority of patients treated in our department
choose the Chêneau light™ brace, the Gensingen brace™
is used in curvature patterns a Chêneau light™ brace is
not available for, or for curvatures exceeding 50°. Therefore, a direct comparison of the results achieved with
both brace types will not be possible in the near future.
Page 12 of 18
Nevertheless, we have documented case reports showing sufficient in-brace corrections in certain curve patterns and in bigger curves as well (Fig. 11, 12, 13, 14,
15, 16, 17).
According to the patients’ reports the Gensingen
brace™ is comfortable to wear, when adjusted properly.
Discussion
Several bracing concepts are used today for the treatment of scoliosis and the in-brace corrections accepted
as sufficient vary widely. The plaster cast method worldwide seems to be the most practiced technique at the
moment. CAD systems are available which allow brace
adjustments without plaster. The latest development
however, the ScoliOlogiC® off the shelf system is not
available for all patterns of curvature and for all possible
trunk sizes.
Therefore, with the help of Orthomed Scolicare,
Orthopedic Technical Services in Gensingen a new
CAD/CAM system was developed in Spring 2009 with
the aim to overcome the shortcomings of the CAD/
CAM systems already available in Germany and to
Figure 12 10-year old boy with EOS (early onset scoliosis) in his first Gensingen brace™. Clinically in this boy the flatback is clearly visible.
The trunk is rather balanced because of the re-compensation of the 39° thoracic curve by a structural high thoracic counter curve. The curve is
very stiff and has a bad prognosis, which can be estimated from the x-ray: In the apical area of the thoracic curve a significant wedging of the
vertebra is visible. Nevertheless the curve has been corrected to 18° in the brace, which is sufficient considering the fact that double thoracic
and EOS curves cannot be corrected as easy as single thoracic curves in patients with AIS. The foam pad location is marked on the in-brace xray with wire as is the longitudinal width of the thoracic pad.
Page 13 of 18
Figure 13 Girl with AIS treated with a 3CTL brace. The clinical picture on the left was taken after 6 weeks of brace wearing. The initial
decompensation of the trunk has already disappeared. On the right in the brace the hyper compensation is demonstrated in order to allow a
shift of the apical vertebra towards the midline. The x-ray result is sufficient with a >75% correction of the initial Cobb angle (left) in the
Gensingen brace™ 3CTL.
Figure 14 Girl with double thoracic AIS treated with a 3C brace. On the left the old 2009 model was used initially, on the second picture
from left the final 2010 version of this Gensingen brace™ 3C was finally applied and the recompensation of the curve with a sufficient in-brace
correction effect can be seen on the right.
Page 14 of 18
Figure 15 Tall 12-year old girl from Denmark with double major curvature treated with a Gensingen brace™ 4C. The curve of initially
50° thoracic and 55° lumbar has been corrected to 36° thoracic and 30° lumbar although this specific curve pattern with high lumbar and
middle to low thoracic apex usually corrects least.
Figure 16 Boy with an infantile curvature from Italy treated with a Gensingen brace™ 3C. Treatment began with a Chêneau brace at the
age of 4 years when the boy had 40°. Intermediate result: 28° corrected to 6° in the a Gensingen brace™ 3C
Page 15 of 18
Figure 17 12 year old girl with neuromuscular scoliosis treated with a Gensingen brace™ 3C. The curvature exceeding 60° at the start of
the treatment has been reduced by approximately 50% in the Gensingen brace™ 3C.
enable brace adjustments for patients of all possible
curve patterns (Fig. 18 and 19) and trunk sizes.
In the normal range of brace indications a correction
effect of at least 20% seems necessary to prevent progression [32], while a correction effect of an average
30% promises some final corrections [33]. A correction
effect of 40% and more in a growing adolescent may
lead to a final correction of an average 7° Cobb [6].
Wong et al. [34] reported correction effects of an
average of 40% in patients with an average Cobb degree
of 30, 6° (21° - 43°). However, in this collective, no
patients with double curve patterns were included,
which generally corrected worse than single curves in
our preliminary study using the Chêneau light™ brace
[35].
Bullmann et al. [36] reported average correction
effects of 43% in the custom Chêneau brace constructed
via plaster cast in patients with a Cobb angle of 31° (25°
- 40°). The final rate of success in this study however,
was only 58%, which has to be regarded as rather disappointing, when compared to the success rate of 80% we
reported on in another prospective study [9] with an
average correction effect of less than 40% in custom
Chêneau braces constructed via plaster cast (prospective
controlled study) and compared to the success rate of
about 80% as reported in another independent prospective study [6].
No end result studies on the Gensingen brace™ are
available at this stage, as this is a new application, but
as it uses the Chêneau principles of correction comparable outcomes can be assumed as in the Chêneau braces
investigated previously [6,7,9-11].
As can be seen on Fig. 20 not only the Cobb angle,
but also the clinical appearance of the patient with
respect to trunk symmetry can be corrected by use of
the Gensingen brace™ even in curvatures exceeding 50°.
Conclusions
The use of the Gensingen brace™ leads to sufficient inbrace corrections, when compared to the correction
effects achieved with other braces as described in literature. This has been demonstrated in the cases shown
within this paper.
According to the patients’ reports the Gensingen
brace™ is comfortable to wear, when adjusted properly.
Further studies are necessary (1) to evaluate brace
comfort and (2) effectiveness using the SRS inclusion
criteria.
Page 16 of 18
Figure 18 14 year old girl with a thoracic curve exceeding 60° and with a short lumbar counter curve of 50° treated with a Gensingen
brace™ 4C. The decision was made to counter tilt the pelvis due to the size of the lumbar counter curvature. Although the clinical picture in
the brace looks good we were not able to re-compensate the thoracic curve sufficiently because of a compression effect caused by the lower
ribs included into the lumbar pressure area (arrow).
Figure 19 Same patient as on Fig. 18 with changed brace pattern. After 6 months of treatment with a Gensingen brace™ 4C the lumbar
curve was reduced, however the thoracic curve had increased by 5°. This is why we decided to change the brace to a Gensingen brace™ 3C in
order to get rid of the rib shift on the concave side against the thoracic re-compensation. This is to show that sometimes it is not clear from the
very start which brace may be the best for the patient. Today we address the primary curve at first and risk an increase of the counter curve
when a patient is imbalanced. This allows having the best possible cosmetic result at the very end; however in this patient, there was no more
change of cosmetics. The patient, nevertheless, is satisfied cosmetically and refuses surgery.
Page 17 of 18
Figure 20 Clinical course of a patient treated with the Gensingen brace™. This 13 year old girl with a curvature exceeding 50° has been
compliant after having received her first Gensingen brace™ in March at the first Scoliosis Short-Term Rehabilitation (SSTR) in Gensingen. She has
been compliant and clearly shows an improvement of trunk asymmetry. This is clearly visible when comparing the left waist area after three
months (middle) and after six months (right) of treatment time. Additionally she is exercising regularly.
Additional material
Additional file 1: PDF file containing the basic pattern specific
blueprints according to the augmented Lehnert-Schroth
classification.
Additional file 2: Example of a construction plan as used in
Germany. These construction plans are included with German
description and serve only for documentation purposes within this
article.
Additional file 3: Short appraisal for justification for the new brace,
sheet as used in Germany. These appraisals plans are in German
language and serve only for documentation purposes within this article.
Additional file 4: CPO’s checklist as used in Germany. The checklist is
in German language and serves only for documentation purposes within
this article.
Additional file 5: Physicians Checklist as used in German. The
checklist is in German language and serves only for documentation
purposes within this article.
Acknowledgements
The author is grateful to Orthomed Scoliocare, Orthopedic Technical
Services, Gensingen, Germany, for their kind support, especially to Mario
Werkmann for providing some of the pictures shown.
The author wishes to thank Lesley Schneider for copyediting this paper.
Written informed consent was obtained from the next of kin for all persons’
visible on the pictures submitted.
Authors’ contributions
HRW: Manuscript writing, literature review, analysis and interpretation of
data, preparation of the manuscript, acquisition of pictures and additional
materials,
Competing interests
The author is applying for a patent relating to the content of this paper
(Chêneau light™ brace) and is advisor of Koob-Scolitech, Abtweiler, Germany
(http://www.koob-scolitech.com).
Received: 1 September 2010 Accepted: 13 October 2010
Published: 13 October 2010
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Skoliosetherapie Georg Thieme Verlag, Stuttgart 2000.
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doi:10.1186/1748-7161-5-22
Cite this article as: Weiss: “Brace technology” thematic series - the
Gensingen brace™ in the treatment of scoliosis. Scoliosis 2010 5:22.
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"Brace technology" thematic series

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